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CYSTIC FIBROSIS SERVICES, LLC
SCH240088-00 Rice Memorial Hospital
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Covered Entity Details
Entity Name
Rice Memorial Hospital
Subdivision Name
Type
Sole Community Hospital
340B ID
SCH240088-00
Entity Address
301 Becker Ave. SW
Willmar, MN 56201
Medicare Provider Number
240088
Participating Start Date
10/1/2011
Last Recertification Date
11/16/2017
Entity Termination Date
6/25/2018
Pharmacy Details
Pharmacy Name
CYSTIC FIBROSIS SERVICES, LLC
Pharmacy Address
DBA WALGREENS SPECIALTY PHARMACY #16280
10530 JOHN W ELLIOTT DR STE 200
FRISCO, TX 75033
Pharmacy Comments
Contract Details
Approval Date
6/29/2017
Contract Begin Date
7/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
7/1/2018
Covered Entity Terminated
Contacts
Covered Entity Signing Official
William Fenske, Chief Financial Officer
(320) 231-4009
Contract Pharmacy Representative
Walgreens
Karl Meehan, Vice President, Health Systems Programs
(847) 315-2663
Signed By Date
6/29/2017
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